* = Required Information
Last Name
*
First Name
*
Middle I.
Please mark the corresponding experience level for each section
A=Able to perform without any supervision
B=Perform infrequently (would require some supervision)
C=No experience
CARDIOVASCULAR
GENERAL
Auscultate heart sounds
A
B
C
Arrhythmia - identify/interpret
A
B
C
CPR (child/adult)
A
B
C
O2 therapy
A
B
C
Cardioversion / Defibrillation
A
B
C
12 lead EKG - obtain/interpret
A
B
C
Cardiac enzymes - interpret
A
B
C
Pacemakers - assist with insertion
A
B
C
Start IV's
A
B
C
Central venous line - assist with insertion
A
B
C
Arterial line - assist with insertion
A
B
C
Swan-ganz catheter - assist / interpret
A
B
C
CVP - set up/ use / interpret
A
B
C
Pericardiocentesis - assist
A
B
C
CARE OF PATIENT WITH:
Acute angina
A
B
C
Acute CHF
A
B
C
Acute MI
A
B
C
Cardiac Arrest
A
B
C
Thrombolytic therapy
A
B
C
Administration of blood / blood products
A
B
C
Abdominal aortic aneurysm
A
B
C
Pre / post PTCA
A
B
C
PULMONARY
GENERAL
Aucultate breath sounds
A
B
C
Ventilation with ambu bag
A
B
C
ABG - obtain/interpret
A
B
C
Chest tube - assist with insertion
A
B
C
Administer O2 (mask/canula)
A
B
C
Airway management/suctioning
A
B
C
Intubation/ extubation - assist
A
B
C
Inhalers/ Nebulizer treatments
A
B
C
Ventilator management
A
B
C
Bronchoscopy - assist
A
B
C
Tracheostomy - assist
A
B
C
Thoracentesis - assist
A
B
C
CARE OF PATIENT WITH:
ARDS
A
B
C
COPD
A
B
C
Aspiration
A
B
C
Hemothoax
A
B
C
Tension pneumothorax
A
B
C
Pulmonary emboli
A
B
C
Pulmonary edema
A
B
C
GASTROINTESTINAL
GENERAL
Auscultate bowel sounds
A
B
C
Assess nutritional status
A
B
C
Assess fluid balance
A
B
C
Naso / oro - gastric tube insertion
A
B
C
Gastric lavage
A
B
C
CARE OF PATIENT WITH:
Acute GI bleed
A
B
C
Acute abdominal disorders
A
B
C
Bowel obstruction
A
B
C
Liver failure
A
B
C
NEUROLOGY
GENERAL
Neuro assessment
A
B
C
Monitor neurological signs
A
B
C
Use of Glascow Coma Scale
A
B
C
Seizure precautions
A
B
C
Transport of patient with spinal cord injuries
A
B
C
Lumbar puncture- assist
A
B
C
ICP - monitor
A
B
C
CARE OF PATIENT WITH:
Closed head injury
A
B
C
Cerebral hemorrhage/Aneurysms
A
B
C
Acute spinal cord injury
A
B
C
Acute TIA/CVA
A
B
C
Drug overdose
A
B
C
DT's
A
B
C
Encephalitis / Meningitis
A
B
C
Seizures
A
B
C
Encephalitis / Meningitis
A
B
C
Seizures
A
B
C
ORTHOPEDICS
GENERAL
Circulation - assess
A
B
C
Range of motion - assess
A
B
C
Gait - assess
A
B
C
Application of orthopedic appliances
A
B
C
Closed fracture/Dislocation reduction - assist
A
B
C
Casts - application /set up
A
B
C
Braces
A
B
C
Splints
A
B
C
Cervical collar
A
B
C
Sling
A
B
C
Immobilers
A
B
C
Pinned fractures
A
B
C
Transfer boards
A
B
C
Sedation monitoring
A
B
C
RENAL / GENITOURINARY
GENERAL
Renal / GU system - assess
A
B
C
Urinary tubes - insert / irrigate
A
B
C
A-V fistula / Shunt
A
B
C
CARE OF PATIENTS WITH
Acute renal failure
A
B
C
Renal trauma
A
B
C
Peritoneal dialysis
A
B
C
Hemodialysis
A
B
C
OB/GYN
GENERAL
Rape kit
A
B
C
Pelvic exam - assist
A
B
C
Reporting procedures for acts of violence
A
B
C
CARE OF PATIENTS WITH
Acute hemorrhage
A
B
C
Abruptio placenta
A
B
C
Spontaneous abortion
A
B
C
Placenta previa
A
B
C
Preterm labor
A
B
C
DIC
A
B
C
Pre-eclampsia / eclampsia
A
B
C
TRAUMA/BURNS
GENERAL
Triage
A
B
C
Transportation
A
B
C
Mast suit application
A
B
C
Poison index
A
B
C
Champion trauma score
A
B
C
Rule of Nine
A
B
C
Sutures - assist/removal
A
B
C
Staples - assist/removal
A
B
C
Irrigation - eye
A
B
C
Irrigation - ear
A
B
C
Use of Morgan lens irrigation
A
B
C
Eye patch application
A
B
C
Nasal packing
A
B
C
Remove contact lens
A
B
C
Fluorescein /woods lamp exam set-up
A
B
C
Visual acuity
A
B
C
Pain management
A
B
C
CARE OF PATIENTS WITH
Minor burns
A
B
C
Major burns
A
B
C
Minor trauma
A
B
C
Major trauma
A
B
C
Dehydration
A
B
C
Near drowning
A
B
C
Anaphylactic shock
A
B
C
Cardiogenic shock
A
B
C
Neurogenic shock
A
B
C
Septic shock
A
B
C
Hypothermia
A
B
C
Hyperthemia
A
B
C
Amputations
A
B
C
Hazardous material exposure
A
B
C
Radiation exposure
A
B
C
Bites - human / animal
A
B
C
Electrocution
A
B
C
Gunshot wounds
A
B
C
Stab wounds
A
B
C
PEDIATRICS
Obtaining consent to treat
A
B
C
Calculating emergency medication dosages
A
B
C
Pediatric CPR
A
B
C
Child abuse - recognise/report
A
B
C
Epiglottitis
A
B
C
Near drowning
A
B
C
Overdose/poison ingestion
A
B
C
Status asthmaticus
A
B
C
MISCELLANEOUS
Suicide precautions
A
B
C
Fever management
A
B
C
Universal / specific precaution
A
B
C
Isolation
A
B
C
Snake bite
A
B
C
Psychiatric Disorders
A
B
C
T.P.A
A
B
C
Aseptic Technique any type of wound
A
B
C
Assessing emotional needs of patient & Family
A
B
C
Patient Teaching & Discharge instructions
A
B
C
Administration & Monitoring of Following Meds:
A
B
C
Atropine
A
B
C
Lidociane
A
B
C
Bretylium
A
B
C
Cardizem
A
B
C
Charcoal
A
B
C
Dilantin
A
B
C
Dopamine
A
B
C
Dextrose
A
B
C
Digoxin
A
B
C
Dobutamine (Dobutrex)
A
B
C
Dopamine
A
B
C
Epinephrine
A
B
C
Ipecac
A
B
C
Lasix
A
B
C
Pavulon
A
B
C
Phenobarbitol
A
B
C
Pronestyl
A
B
C
Nitroglycerine Drip
A
B
C
Nitride
A
B
C
Mannitol
A
B
C
Steroids
A
B
C
Valium
A
B
C
Versed
A
B
C
AGE EXPERIENCE
Indicate groups in which you have expertise in providing, age-appropriate nursing care.
0 - 30 Days
Yes
No
30 Days - 1 year
Yes
No
1 - 5 years
Yes
No
5 - 13 years
Yes
No
13 - 18 years
Yes
No
18 - 39 years
Yes
No
39 - 64 years
Yes
No
64 years +
Yes
No
The information that I have given is accurate and true to the best of my knowledge. I hereby authorize Pace Medical Staffing, Inc. to release same to her client health care facilities.
Signature
*
Date
Submit